Every finding on record at Odyssey Healthcare Operating B, LP

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon patient record review 1 of 19 (Patient #9) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #9 start of care date of 9/15/23, the initial spiritual assessment completed on 9/21/23.

Upon patient record review, 2 of 19 (Patient #7, #8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Duplicate drug therapy Patient #7 The medication list revealed orders for Acetaminophen 325mg po 2 tablets every 4 hours for pain and Morphine concentrate 100mg/5ml (20mg/ml) oral solution 0.25ml every hour for pain. No pain parameters were found for either pain medication. This was corrected on site Patient #8 The medication list revealed orders for Acetaminophen 325mg po 2 tablets every 4 hours for pain and Morphine concentrate 100mg/5ml (20mg/ml) oral solution 0.25ml every hour for pain. No pain parameters were found for either pain medication. This was corrected on site

Upon patient record review, 2 of 19 (Patient #2, #5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #2 start of care date of 9/13/23. The bereavement assessment was complete 9/19/23. Patient #5 start of care date of 9/7/23. The bereavement assessment was complete 9/13/23.

Upon patient record review, 2 of 19 (Patient #3 and #4) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #3 The initial plan of care included frequency for both social worker and spiritual care provider was one PRN, without evidence of a routine visit frequency. Patient #4 The initial plan of care included frequency for both social worker and spiritual care provider was one PRN, without evidence of a routine visit frequency.

Upon patient record review, 2 of 19 (Patient #7, and #8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #7 The orders for Acetaminophen 325mg po 2 tablets every 4 hours for pain and Morphine concentrate 100mg/5ml (20mg/ml) oral solution 0.25ml every hour for pain. No pain parameters were found for either pain medication. This was corrected on site. Patient #8 The orders for Acetaminophen 325mg po 2 tablets every 4 hours for pain and Morphine concentrate 100mg/5ml (20mg/ml) oral solution 0.25ml every hour for pain. No pain parameters were found for either pain medication. This was corrected on site.

Upon client record review, 2 of 19 (Patient #1 and #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 ordered frequency of two times a month for two months for the SW. However the record revealed the SW only went once in September on the 19th. Patient #4, ordered RN frequency of two times per week starting the week of September 10th, however only one visit on 9/15/23 was noted.

Upon patient record review, 1 of 19 (Patient #11) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient #11 The clinical record revealed an initial social worker assessment completed on 8/21/23, stating in the narrative portion, the patient's son requested joint visits with the SW and RN. The record failed to reveal evidence that the SW coordinated visits to correspond with the RN visits. The RN frequency on this patient was twice a week. Furthermore, the SW documented on two occasions 9/20/23 and 9/21/23, that missed visits occurred, these visits were not in coordination with the RN visits. The RN completed visits on 9/18/23 and 9/19/23.

Upon patient record review, 1 of 19 (Patient #4) did not have evidence in the patient record that hospice aide assignments and duties are: • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #4 The clinical record revealed a task on the aide care plan for the aide to provide stand by assist with ambulation every visit PRN.

Upon patient record review 1 of 19 (Patient #4) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #4 the clinical record revealed an aide frequency of weekly, however during the week of September 17th no aide visit was found.

Upon patient record review 1 of 19 (Patient #11) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #11 The clinical record revealed a start of care on 8/16/23 with aide services starting on 8/18/23. No evidence of supervisory visits until 9/18/23.

Upon personnel record review, 1 of 13 (Personnel #2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #2 No evidence of a signed job description for the alternate administrator position.

Upon patient client record review, 4 of 19 (Patient #3, #4, #5 #13) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #3 had elected to receive a copy of non-covered items, services and drugs on 8/30/23, when the election form was signed and dated, however the non-coverage form revealed no date furnished. Patient #4 had elected to receive a copy of non-covered items, services and drugs on 9/1/23, when the election form was signed and dated, however the non-coverage form revealed no date furnished. A second form was also completed on 10/4/23 but revealed no date furnished. Patient #5 had elected to receive a copy of non-covered items, services and drugs on, when the the election form was signed and dated, however the non-coverage form revealed no date furnished. Patient #13 had elected to receive a copy of non-covered items, services and drugs on 9/22/23, when the election form was signed and dated, however the non-coverage form revealed no furnished date. A second form was also completed on 9/29/23 and did not reveal a furnished date.

Upon patient client record review, 3 of 19 (Patient #3, #5, #11) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #3, The clinical record revealed no frequency for a home health aide, the patient and family had declined services. Despite this the RN continued to do supervisory visits on the following dates; 9/20/23, 9/23/23, 9/26/23, and 9/27/23. The notes indicated that supervisory functions were performed, although there were no aide services during this period of time. Patient #5, The clinical record revealed no frequency for a home health aide, the patient and family had declined services. Despite this the RN continued to do supervisory visits on the following dates; 9/12/23, 9/19/23, 9/26/23, 10/2/23, and 10/10/23. The notes indicated that supervisory functions were performed, although there were no aide services during this period of time. Patient #11, The clinical record revealed an aide frequency of once a week for one week then twice a week for 12 weeks. The aide frequency was then discontinued on 8/30/23. The record further revealed the RN conducted supervisory visits on 9/28/23, 10/4//23, and 10/16/23, indicating that there were supervisory functions performed, although there were no aide visits during this period of time.